Next steps

This Interim Report does not provide final recommendations of the actions needed to improve the performance of the system or the equity of outcomes from the system.

The purpose of the Interim Report is twofold. To reflect back to the community and the sector what the Panel read, heard, and observed about the main issues affecting sector performance and the things that are working well that we can learn from. Second to indicate the directions of change the Panel believes are necessary.

This report should contain few surprises. We observed a high degree of consensus on the issues preventing the system being as effective as it could be.

There is much less consensus on the best way forward.

The reality is that the world is rapidly changing. Changing demographics alone will increase demands on the system making it unsustainable unless it operates very differently in the future.

Consumer expectations are changing. New technologies, climate change, increasing comorbidities, and growth in antimicrobial resistance etc are happening whether the system changes or not. But their impact on system performance for the least well off will be hugely different, depending on what actions are taken now.

Phase Two of the review will, therefore, focus on developing recommendations for the key changes that can best move the system towards more sustainable and fairer performance. We have indicated throughout this report the direction the Panel believes those changes should take, and these are set out below.

Developing our final recommendations will require us to answer specific questions in each of our focus areas. These questions include, but are in no way limited to, those set out in the next sections.

Settings

The Panel is clear that a more integrated health and disability system is needed that operates within an agreed set of values and principles, with clear decision frameworks, national long-term planning, and explicit accountabilities. The Panel is also clear that the mana of Māori as Tiriti / Treaty partner with the Crown must be reflected in the way the system is governed and in how and what services are provided.

Issues which need further analysis and discussion however include:

• In taking a Tiriti / Treaty based approach in health, what are the implications for the role of Māori and iwi in leadership, governance, and decision making at national or local levels and how should these roles be provided for?
• What is an appropriate set of values and principles to guide the operation of publicly funded health and disability services in New Zealand?
• How does New Zealand build leadership in the system and enforce real accountability for performance at all levels?
  Where should responsibility for developing and implementing the system-wide long-term plan lie?
• What should be the balance between national decision making to guide the entire system and local autonomy to ensure services are designed to meet the needs of all communities?
• How can local communities have a meaningful say in how their services are planned and provided?
   Is continuing with governance by majority-elected boards, the most effective way to improve accountability or foster real community engagement?
• Is the best way to achieve more efficiency and more equitable outcomes within available resources to have fewer DHBs, DHBs with different functions and/or more sharing of resources at regional or national level?
• Should development of the health and disability system into a cohesive, integrated system with greater clarity of mandate, be driven centrally by the Ministry of Health or by a different agency?
• How should funding regimes change to provide more predictability to providers, more accessibility to consumers, and more accountability to government?
• How do we ensure that the mix of public and private business models engaged in the sector operate more effectively together, better manage conflicts of interests, and result in a mix of service provision that improves equity of outcomes?
  What accountability mechanisms should be applied to ensure both improved health outcomes and financial balance are achieved over time?

Services

For many years, various health strategies have promised more emphasis on population health and early intervention to shift the focus from treatment to health and wellbeing. However, despite many good examples of local initiatives changing how services are designed and provided for small groups, there is no evidence of a large scale or sustained movement away from a treatment focus towards a prevention focus. Nor is there evidence of the wellbeing of individuals and communities being recognised as the main factor that should be driving the design of service provision.

The Panel is clear that progress for those individuals and communities who are currently missing out in the system, hinges crucially on two things happening. First, services need to be funded and provided in a way that enables them to be designed around the wellbeing of the individual and their whānau, rather than primarily the interests of providers. Second, services need to be available to all on a fair basis, so that where you live, your degree of disability, or your ethnicity is not a determining factor in the quality of care you receive.

Issues which need further analysis and discussion in these areas include:

• If population health is to be more central to all planning and delivery in the system, should this change be driven by the local DHB or at a regional or national level?
• How do we ensure that what the consumers value is accorded highest priority?
• How do we ensure that Māori communities have access to appropriate kaupapa Māori services?
• How do we ensure that mātauranga Māori is properly reflected in service provision?
• How should the co-payment regimes and eligibility criteria for access to various Tier 1 services be rationalised?
• Given the desire for more reliance on integrated community health hubs, how should these be funded?
• Do PHOs in their current configuration add value to the provision of services?
• Given the increasing numbers of people living with some disability, how can further fragmentation of the systems designed to provide support be avoided?
• How do we increase the visibility of the needs of people with disability to ensure the system properly addresses their health needs as well as needs for disability support?
• How can better use be made of technology and local resources to ensure that rural communities have access to a full range of services?
• How can continuous improvement be embedded firmly into hospital systems with clinicians actively involved and accountable for building a networked system so the public has confidence that best practice will be applied throughout the country?
• Who should be accountable for decision making about new technologies, new services, and the development of guidelines and pathways and for setting thresholds for treatments? How can international work be incorporated and localised?
• How does New Zealand ensure its system of hospitals operates effectively as a network that delivers a fair distribution of complex services and better support to the provision of local services in smaller hospital and community settings?

Enablers

The health and disability system workforce is the foundation on which the system is built. But the workforce is under considerable stress because of a shortage of supply and the prospect of ever-increasing demand for health and disability services. While technology offers an opportunity for positive change in the way services are provided, it will never remove the need for good interaction between health workers, consumers and their families and whānau.

For the workforce to be effective in the future, various enablers need to be strengthened. Principal among these is for the system to produce and use much better data. The future of the system, as with all other sectors, is largely digital, but the ability to apply that technology effectively depends on data systems being up to scratch. Our report suggests this is not the case at the moment, so priority needs to be given to improving data collection, analysis, and stewardship and to making technology systems properly interoperable.

The health and disability system is always going to need a significant amount of capital investment to provide the population with access to modern, safe, and appropriate facilities. The recent history of capital and infrastructure management in the system is not impressive, and there is little confidence in the transparency or credibility of the decision-making mechanisms. The Panel is clear a national asset management plan and a long-term investment strategy are needed as part of the long term service plan.

Many issues need further analysis and discussion. These include:

• How can the strategic partnership between unions and sector employers be strengthened so the system can operate in ways that best suit the needs of consumers while at the same time protecting the rights and wellbeing of workers?
• How can training and regulatory regimes be developed so the workforce can gain and use the skills needed to adapt to the changing demand for services?
• How can the workforce of the future become more representative of the communities it is serving?
• What needs to change to make multidisciplinary teamwork the norm rather than the exception?
• How can data stewardship regimes be put in place to give all communities the confidence that their data will be protected and used appropriately and according to their permissions, while at the same time allowing appropriate sharing of information throughout the system?
• How can work done in other jurisdictions in regard to data standards, identity management, interoperability, and the like be best used?
• Would a centralised model for infrastructure projects be more effective?

What happens next?

The questions above are illustrative, not exhaustive, and the questions cannot be answered by the Panel alone. The process from here will involve the Panel calling on people in the sector to work with it on various working groups to come up with more detailed options.

Many groups have already submitted quite detailed proposals, particularly relating to possible configuration of Tier 1 services, and the Panel intends to use these as a base to develop further.

As options are developed, further opportunities will be provided for interested parties to comment before the next report is finalised in March 2020.